Applied Health Research, University College London, London, UK
Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
BMJ Qual Saf. 2024 Aug 16;33(9):587-596. doi: 10.1136/bmjqs-2022-015620.
. In this case study of hyperacute stroke wards which provide initial stroke investigation, treatment and care, we explored temporal structuring patterns to explain how these may affect quality of care.
This paper presents a thematic analysis of qualitative interviews with hyperacute stroke staff (n=76), non-participant observations (n=41, ~102 hours) and documentary analysis of the relevant service standards guidance. We used an inductive coding process to generate thematic findings around the concept of temporal structuring, with graphically illustrated examples.
Five temporal structures influence what-happens-when: (1) clinical priorities and quality assurance metrics motivate rapid activity for the initial life-prolonging assessments and interventions; (2) static features of ward organisation such as rotas and ward rounds impact consistency of care, determining timing and quality of care for patients; (3) some services experimented with staff rotas to try to meet peaks in demand, sometimes unsuccessfully; (4) implicit social norms or heuristics about perceived necessity affected staff motivation to make changes or improvements to consistency of care, particularly around weekend work; and (5) after-effects such as bottlenecks or backlogs affect quality of care, which are hard to measure effectively to drive service improvement.
Patients need temporally consistent high quality of care. Temporal consistency stems from the design of services, including staffing, targets and patient pathway design as well as cultural attitudes to working patterns. Improvements to consistency of care will be limited without changes to structures such as rotas and ward rounds, but also social norms around weekend work for certain professional groups.
本案例研究聚焦于超急性脑卒中病房，这些病房提供脑卒中初始评估、治疗和护理。本研究旨在探讨时间结构模式，以解释其如何影响护理质量。
本文对超急性脑卒中病房的医护人员（n=76）进行了专题分析，包括定性访谈、非参与式观察（n=41，约 102 小时）和相关服务标准指南的文件分析。我们使用归纳式编码过程生成了围绕时间结构概念的主题发现，并以图形方式举例说明。
有五种时间结构会影响事情发生的先后顺序：（1）临床优先级和质量保证指标促使快速进行初始延长生命的评估和干预；（2）病房组织的静态特征，如轮班和查房，影响护理的一致性，决定患者护理的时间和质量；（3）一些服务尝试改变工作人员轮班，以满足需求高峰，但有时并不成功；（4）关于必要性的隐含社会规范或启发式认知会影响工作人员改变或提高护理一致性的积极性，特别是在周末工作方面；（5）后续影响，如瓶颈或积压，会影响护理质量，而这些难以有效衡量，难以推动服务改进。
患者需要时间上一致的高质量护理。时间一致性源于服务设计，包括人员配备、目标和患者路径设计以及对工作模式的文化态度。如果不改变轮班和查房等结构，也不改变某些专业群体对周末工作的社会规范，那么护理一致性的改进将受到限制。
